What is a healthy first-pass resolution rate?
First-pass resolution rate is the percentage of claims paid in full on first submission without requiring any additional action from the practice.
Quick answer
A healthy first-pass resolution rate (FPRR) is 90 percent or higher, meaning at least 90 percent of claims are paid in full on first submission without rework or appeal.
The detail
FPRR is a stricter metric than clean claim rate. Clean claim rate measures whether the claim was accepted by the clearinghouse and payer for processing. FPRR measures whether the claim was actually paid in full on first adjudication. The gap between the two is the work your billing team has to do on accepted-but-underpaid claims. HFMA MAP Keys defines high-performer FPRR at 90 percent or higher; industry median is closer to 80 to 85 percent per RCM benchmarks. The biggest drivers of FPRR drag are bundling and unbundling errors, modifier issues, medical necessity documentation gaps, prior authorization mismatches, and contractual underpayments where the payer pays less than the contracted rate. The last category is often invisible because the claim shows as paid; only systematic contract reconciliation surfaces underpayments.
HFMA MAP Keys defines high-performer first-pass resolution rate at 90 percent or higher.
Source: HFMA MAP Keys
Contractual underpayments are estimated to affect 7 to 11 percent of paid claims per industry RCM analyses.
Source: HFMA Revenue Integrity resources
Modifier 25 issues are among the top five causes of payer takebacks and audits per AAPC.
Source: AAPC
What this means for clinic owners
From Sorso
FPRR is the metric that catches contractual underpayments. If you only track clean claim rate and net collection rate, you can have an FPRR of 75 percent and never see it. Add it to your monthly KPI report and review it by payer.
Related questions
What is a good clean claim rate?
A good clean claim rate is 95 percent or higher on first submission, per HFMA MAP Keys. Most outpatient practices average 85 to 92 percent, leaving meaningful revenue stuck in rework.
What is a healthy denial rate?
A healthy initial denial rate is under 5 percent of submitted claims, with denial write-offs under 2 percent of net patient revenue per HFMA MAP Keys. Industry averages have climbed above 11 percent.
What is modifier 25 used for?
Modifier 25 indicates that a significant, separately identifiable Evaluation and Management (E/M) service was performed by the same physician on the same day as a procedure, allowing both to be billed when properly documented.
What are the most common billing errors in healthcare?
The most common healthcare billing errors are eligibility verification failures, missing prior authorization, incorrect or missing modifiers (especially modifier 25 and 59), upcoding/downcoding, missing documentation for medical necessity, and timely filing failures.
Sources
Founder of Sorso. 19 years in corporate finance. Managed a $450M loan portfolio before building a fractional CFO firm exclusively for healthcare clinics.
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